While one is fully rationale, we should complete the official
forms for our state that name a person to make medical decisions when you
are unable to, and any directives for the kind of care you want to receive
and treatments you do not want. State Legislatures change the laws about these
forms, so it is also important to be sure the forms you signed agree with
current state requirements. In addition, an attorney friend prepared the following
form, conferring with physicians, and distributes it in our area. He gave
me permission to publish it here. You may print it.

If you want to use it, first check with your primary care physician
and attorney. They may suggest changes. Sign and witness it, giving copies
to those who need to have it.

A Personal
Directive To My Family, Physician(s),
Caretakers, And Agent Concerning A Good Death

A. I have tried to lead a good life and, like all generally rational people,
I desire a good death when that time comes. I hope that it will be swift, without
excessive pain, peaceful, and that those I love will be with me so that we can
say our good-byes and so I can receive their support, preferably in a comfortable
and familiar environment. I know that all does not go as we wish or as we plan,
so I have set down this statement of my wishes in the hope that doing so will
enable me to achieve a good death. I make this Personal Directive at a time
when I am mentally competent and after much study and thought.
B. The Directive to Physicians, Family, and Surrogates I have executed makes
clear that should I have a terminal condition or an irreversible condition,
I do not want to receive life-sustaining procedures that will serve only to
prolong my dying. This situation is relatively easy to manage in comparison
to other physical or mental conditions that will rob me of dignity, mental capacity,
and all that is meaningful to my life. For this reason, I have executed a Worksheet
for Planning Medical Decisions which is attached to this Directive. I direct
that that document be honored.
C. Still, there are two other types of debilitating conditions that will keep
me from continuing to live a good life and have a good death.

One is irreversible loss of normal mental functioning caused by Alzheimer's
or another form of dementia or injury that makes me incapable of ending my
own life due to mental incapacity, and

the other is the irreversible loss of the physical ability to personally
end my life in circumstances where I am mentally competent but cannot live
a good life or have a good death.

In both of these two situations, after the conditions described above have
been confirmed by a physician, I will need assistance in dying, but I do not
want to endanger anyone or cause them to suffer prosecution by the government
for assisting in ending my life. To this end, I have formulated the following
guidelines and a directive which I hope will enable my family, friends, and
agent to help me achieve a good death without the danger or the reality of criminal
sanction.

Guidelines for a Good Death Under the Circumstances Described Above, with appropriate
Directive:
1. The best and legally safest course of action is to prohibit anyone from feeding
or hydrating me, or providing artificial nutrition and hydration. I should be
able to die relatively peacefully and without pain or discomfort. I consider
nutrition and hydration, whether natural or artificial, to be medical treatments
or therapy under the circumstances described in this directive and I have determined
that they are not acceptable medical treatments or therapy for me under the
circumstances described above.
2. If my condition becomes painful at any time during the course I have described
above; causes me discomfort (including stiffening or grimacing spontaneously);
or I become confused and agitated; have hallucinations; experience delirium;
suffer dyspnea; have unrelenting, persistent, unacceptable symptoms, such as
extreme fatigue, weakness, or debility; or have seizures, I want to receive
palliative care, including terminal sedation if necessary, sufficient to eliminate
the symptoms described above, even if the medications hasten the moment of my
death.
3. While this option may require finding an understanding physician if the physician-in-charge
will not honor my wishes, this method should be possible to carry out with minimal
conflict and difficulty.
4. It may be possible to receive hospice care during this period of dying, so
long as hospice is committed to carrying out my wishes.
5. No one will need to do anything except assure that my wishes to receive no
food or hydration, or artificial nutrition or hydration are honored. If I am
mentally competent and able to communicate my wishes by some reliable means,
I should be asked only whether I want to have this directive carried out. The
details should not be discussed with me if I reach this point.

DIRECTIVE: To assist me with carrying out these wishes under the circumstances
described above in paragraph C, I direct that no one be permitted to offer me
food, liquids, artificial nutrition, or hydration by medical means unless I
request it; nor may anyone bring food into my presence or within range of my
ability to smell it or see it. The use of cracked ice by mouth to relieve any
dryness around my lips and mouth is acceptable care, however, as are other treatments
for such dryness. If I am able to swallow, and taking medication by mouth is
appropriate, I may take fluids only as are necessary for the administration
of the medication.